STATE OF NEW JERSEY CERTIFICATE OF ELIGIBILITY

1 CLEAR FORM. STATE OF NEW JERSEY . CERTIFICATE OF ELIGIBILITY . (This form must be completed for each transfer of a Shotgun, Rifle, including black powder or BB Rifle). Part 1: This section must be completed by the transferor (seller or giver) of the firearm. Make of Firearm:_____ Action: _____. Pump, Lever, Semi-Automatic, Bolt etc. Model of Firearm: _____ Caliber or Gauge: _____ Serial #:_____. Name of Transferor (or Dealer Employee): _____. Last First MI. Dealer Name (if applicable): _____ Dealer's STATE License Number: _____. Address of Transferor: (Dealer: list your licensed location). _____. Street Town/City STATE Zip Code Transferor's Firearms Card Number:_____ Date of Transfer: _____. Part 2: This section must be completed by the person receiving (receiver of) the firearm. Name of Receiver: _____ _____. Last First MI Telephone Number Address: _____. Street Town/ City STATE Zip Code Date of Birth: _____ Firearms Purchaser Number:_____.

2 1) Have you ever been convicted of a crime that has not been expunged or sealed? .. q Yes q No 2) Are you subject to any court order prohibiting you from possessing firearms?.. q Yes q No 3) Are you subject to any court order issued pursuant to Domestic Violence? NOTICE: If you have had a Final Restraining Order issued against you within the last two years, you must answer Yes and are ineligible to possess a firearm. The period of ineligibility is two years from the date of issuance of the Final Restraining Order or the date it was dismissed whichever is q Yes q No 4) Have you ever been convicted of a disorderly persons offense or its equivalent, in any jurisdiction, involving an act of domestic violence that involved the offense(s) of (1) Simple Assault (2) False Imprisonment (3) Lewdness (4) Criminal Trespass or (5) Harassment that has not been expunged or sealed? .. q Yes q No 5) Are you an alcoholic?

3 NOTE: A recovered alcoholic may answer no to this q Yes q No 6) Are you dependent upon the use of any narcotic or other controlled dangerous substance? .. q Yes q No 7) Do you suffer from any physical defect or sickness which makes it unsafe for you to handle firearms?.. q Yes q No 8) Since the issuance of your firearms card, have you been confined for a mental disorder? .. q Yes q No 9) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of violence, either to overthrow the government of the United states or of this STATE , or to deny others of their rights under the Constitution of either the United states or the STATE of New JERSEY ?.. q Yes q No 10) Are you a fugitive from justice? .. q Yes q No 11) What is your STATE of residence? _____ If other than NJ, this transfer must go through a licensed firearms dealer. _____ _____.

4 Signature of Transferor Signature of Receiver Should you have any questions in completing this form, contact the Fire- I hereby certify that the answers given on this form are complete, true arms Investigation Unit, New JERSEY STATE Police, Box 7068, West and correct in every particular. I realize that if any of the foregoing an- Trenton, NJ 08628-0068 (609) 882-2000 Ext. 2060 or 2061. swers made by me are false, I am subject to punishment. Questions 1 - 10 must be answered no for the transfer of the firearm to proceed. Falsification of this form is a crime of the third degree as provided A person who answers yes to any question is not eligible to receive a firearm. in NJS 2C:39-10c White copy is to be retained by the transferor pursuant to 2C:58-3b. Yellow copy is to be retained by the receiver. 634 (Rev. 04/05) If internet form, make and sign two copies.